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OBJECTIVE. The purposeof this investigationwasto determinethe prevalenceof lower esophagealmucosal rings and to correlate the relationship between these mucosal rings and thepresenceandanatomiclevel of symptomsevokedusinga marshmallowbolus. SUBJECTS AND METHODS. Our prospective studyincluded130 patientswho under went bariumexaminationof the esophagus. All patientscompleteda questionnaireregarding the anatomic location of their symptoms of dysphagia. In addition to a multiphasic examina tion of the esophagus, all patients also underwent fluoroscopic observation and videotaping while swallowing a marshmallow bolus; any symptoms that were provoked were recorded.RESULTS. Lower esophageal mucosalringswere shownin 26 (20%) of the 130 patients. The diameterof the ringswas 9â€"12 mm in six patients,13â€"20 mm in 18 patients,and larger than 20 mm in two patients. In 16 (62%) of the 26 patients, a marshmallow bolus became im pacted at the ring; the impaction caused dysphagia in 12 (75%) of the I6 patients. In these 12 patients, dysphagia was referred to the neck in seven,the sternal angle in two, the mid chest in two, and the lower chest in one patient. None of the 12 patients had a pharyngeal or cervical esophageal abnormality that would account for their symptoms.CONCLUSION. Becauseproximal referral of symptomsis common in patientswith loweresophageal mucosalrings,a thoroughradiographicexaminationof theentireesophagus and esophagogastricregion is required regardlessof the level of their swallowing complaints.

Forty-six patients with cerebrovascular disease underwent videofluoroscopic examination of the oropharynx to assess location and severity of swallowing dysfunction with use of boluses of various consistencies. Low- and high-viscosity barium suspensions, a barium paste, and a paste-coated cookie were used; not all patients were given all materials. Thirty-nine patients had abnormalities of both oral and pharyngeal function. Two patients had oral dysfunction only, and five had pharyngeal abnormalities only. Mild swallowing difficulties occurred in 18 patients (39%), moderate dysfunction in 23 (50%), and severe dysfunction in five (11%). Thirty-one patients had pharyngeal stasis, which was symmetric in 25 patients (81%), right-sided in three, and left-sided in three. Asymmetric stasis did not correlate to the site of cerebrovascular disease. Twenty-four episodes of aspiration occurred, half of them with the low-viscosity barium suspension. Thus, video-fluoroscopy can be used to define the location and severity of oropharyngeal abnormalities, which is critical for feeding recommendations. The abnormalities present, however, were not useful in predicting the type of cerebrovascular disease.

Diffuse esophageal spasm (DES) is characterized by substernal chest pain, dysphagia, and a manometric pattern of frequent simultaneous contractions with intermittently normal peristalsis. The authors correlated the radiographic and manometric findings in 17 patients with DES to better clarify the role of radiography in the evaluation of this uncommon motility disorder. Incomplete or absent primary peristalsis was observed on radiographs in 13 patients (76%), and mild to severe tertiary activity was seen in 12 patients (71%). The mean estimated thickness of the esophageal wall in patients with DES was 2.6 mm compared with 2.5 mm in an age-matched control group of 17 patients with normal esophageal manometric findings (P greater than .05). The authors conclude that most patients with DES show abnormal esophageal motility on radiographs, although the findings were nonspecific and required clinical and manometric correlation. Esophageal wall thickness was normal in patients with DES and appears to be an overemphasized sign in differentiating DES from other esophageal motility disorders.

. Address correspondence toD.J.Ott. PURPOSE.To We categorized patients by age into three groups: less than 40 years old (n = 31), between 40 and 60 years old (n = 42), and greater than 60 years old (n = 37).

Synchronous video tape fluoroscopy and manometry of the esophagus was performed in 11 subjects (seven men and four women; mean age, 49 years). Four had normal and seven had abnormal esophageal motility (diffuse esophageal spasm, n = 4; nonspecific esophageal motility disorder, n = 3) that was shown by previous manometry. A digital timer appeared on the video tape recording and marked the manometric tracing synchronously. Alternate 5-mL and 10-mL barium boluses were recorded for a total of 10 swallows per patient. Video tape examinations were reviewed prospectively, and the status of primary peristalsis and presence and severity of tertiary activity were noted. A total of 98 swallows (58 normal, 40 abnormal) were correlated, and a 96% agreement was found in assessing primary peristalsis. Overall results of fluoroscopic examinations of each subject during all swallows showed complete agreement with those of manometry; segregating the swallows into groups of five showed 92% concordance. Severe tertiary activity was invariably seen with abnormal primary peristalsis at fluoroscopy.

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